Hans Steiner has trodden a fascinating path throughout life since his adolescents in post-war Vienna, snippets of which I’m sure will arise during his Vienna ESCAP keynote talk. From his home in California, he spoke with ESCAP in a rather secretive manner as not to reveal too much about his talk; he likes to keep us in suspense! However, two aspects he did delve into were the diagnostic criteria for psychiatric disorders, specifically disruptive behavior disorders (DBD), and the need for a developmental trajectory diagnosis for aggression and conduct disorders within these criteria. Hans Steiner is a professor of child, adolescent and adult psychiatry at The Stanford University Medical School. His areas of expertise are eating disorders, psychosomatic disorders, disturbances of attention and impulsivity, and trauma-related psychopathology.
What are the issues with the current DSM and ICD diagnostic classifications?
Hans discusses the flaws of the current Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD) diagnostic classification, specifically for DBD. “These are the start of the clinical process, but we need to go further”. He believes that the way in which the current ICD and DSM handle DBD and the subtypes, such as aggression and anger, is by offering a mere description of the disorders with no real substance behind it. Hans summarizes the situation by using the quote “if you really want to go somewhere in medicine, you have to go beneath the surface”. “This is the issue with the current diagnostic criteria. They describe the disorder but don’t dig underneath the surface. The progression of neuroscience has been phenomenal and this is allowing us to pick under the surface and understand these disorders more” describes Hans, followed by “descriptive psychiatry was this, and descriptive medicine as well, but now we have the tools we need to get out of this mess and evolve. It needs to be a collective effort with neuroscientists at the heart of the exchange”.
“For a diagnosis to be useful, a diagnostic entity is used as a tag that you put on a patient so you can discuss and communicate it with your colleagues and insurance companies etc. and then it should lead you to specific actions, these current labels do not. The types are too heterogeneous, they contain too many pathways to be able to get to conduct disorders. We need to tidy it up.”
What kind of changes need to be incorporated into the ICD and DSM?
In response to this question, Hans uses two books to describe both sides of the coin on what needs to be taken back and re-evaluated in these criteria. ‘Incognito’ by David Eagleman
has a whole chapter on this topic that Hans summarizes by stating David; “let’s not waste our time establishing culpability because in the end, we will have to take into consideration all kinds of neuroscientific limits to culpability, instead turf that and instead spend more time, money, effort etc. on what are we going to do with this person, how likely is she/he going to re-offend, and how to prevent that”.
On the other hand, Lisa Feldman-Barrett
brings the aspects of emotions to the table. Hans also summarizes her book ‘How emotions are made’ by stated “she goes away from the basic emotions argument and she places a lot of value on context. The things we do, think, feel are very much determined, to a certain extent, by the context through an operator. She arrives at a point that the social wrapping has to be worked on and improved”. Both authors have valid points. “The current DBD diagnoses are limited in their power to suggest and lead us to specific and appropriate treatments”. By having different approaches as David and Lisa describe, to understand the reasons behind the actions of individuals with DBD then we can offer an overall picture of the potential outcomes.
Relating this to the justice system, Hans doesn’t agree with the US approach of death penalties for offenders “it’s like an eye for an eye, let’s be more humane about it”. He describes the ideology used in some Swedish, Denmark or Norwegian states that put offenders on remote islands, unable to escape, with little resources and ask them to simply survive. His view, and perhaps why he is a psychiatrist in the first place, “is to understand the actions of these offenders, why did it happen? What broke in their system for them to commit the crime(s)? By doing so, this is the way we will begin to understand people. Ask them about the kind of emotions they get from killing someone for example and let’s put some context to it”.
“Only time and experience will tell how well our classification schemes will evolve to become more useful for the diagnosis and treatment of DBDs. We are in great need of more carefully documented number of prevalence, incidence, and ecological validity from more ideally structured studies” Steiner, Daniels, Stadler & Kelly, Disruptive Behavior
Why does anger lead some to commit a crime, while others can simply walk away from it?
There is a lot of literature on this subject, but Hans uses the work of Johanna Ray-Vollhart
to summarize. “When we get violated in some way, we want to react and the aggression arises, some of us are able to control it and walk away from it, but others get deeper into it. Johanna speaks about the neurobiology underpinning this, most of us can extract from the situation and use some mechanism to cope with the situation. Look carefully at a perpetrator; he is also a victim at some point in his life. Johanna believes this is true, but it depends on what the trauma impinges upon in the neurobiology”. He continues to use examples such as Viktor Frankl
who was a Holocaust survivor and returned back to Vienna after the war. He had a much more altruistic approach and was adamant on helping others who had suffered from severe adversities. He himself obviously went through his own adversities, trauma, maltreatment, so why did he not go the same way and commit the same offences on others?
How do we understand the developmental trajectory of aggression in children, when does it become abnormal?
Hans recent book ‘Disruptive Behavior
’ discusses the developmental trajectory of anger and aggression in children and adolescents. In this interview, he spoke of the work of professor Richard Tremblay
, Quebec “he has beautiful studies showing the impact of early intervention/prevention programs, especially in families of high risk. He studies it as a developmental trajectory or perspective. He has said that the most violent episodes happen before the age of 5. The NICHD followed toddlers for 6-7 years and found that toddlers can emit an aggressive act every 7-10 minutes. Combine that with an aggressive or abusive parent and it’s easy to see why these acts of aggression may persist. The most aggressive period of uncontrolled, hot, emotional aggression occurs around 2-3 years of age, then it reduces. If it doesn’t reduce by 5 years of age, then perhaps there may be some issues with the child or parenting context. It reappears a little bit, mainly due to hormone storms etc. and then it declines again. Planned or cold, mediated aggression arrives around school age, peaks at 13-14 and should then tailor off.”
“Coming back to the DCM, a tiny part of it nods to an age development, by describing pre-10 onset conduct disorders. However, professor Michael Rutter
and colleagues have described that is it necessary to have a combination of developmental and diagnosis to think about how certain dimensions in our functioning arise and disappear over time, and what happens when there are breaking points in these patterns that can relate to certain diagnosis”.
“August Aichhorn brought to these problems the idea that development and psychology play an important role in the pathogenesis of crime and the idea that psychoeducation, therapy, and treatment could alter the course of these youths’ life trajectories” Steiner, Daniels, Stadler & Kelly, Disruptive Behavior
We are all angry at some point
“What we have to remember is that aggression and anger are in all of us. We can all hold our hands up to say we’ve broken the law/rules at least once in our lives, how many parking fines or speeding fines etc. have you had? These are all antisocial acts that we have the ability to do, these behaviors are normal. If we had no ability to get angry or aggressed at something, then what would happen to us in a situation where we need to fight and protect ourselves? The question is, when does this become too much that a serious crime is committed, and how early on can we recognize abnormal, planned acts of aggression in individuals”.
Hans Steiner, as well as presenting his keynote seminar, will also chair an interesting state of the art seminar discussing the work of Hans Asperger. Although not his field of work, Hans had Hans Asperger as a professor and lecturer in his training years back in Vienna. The seminar will consist of two talks, one by Edith Sheffer author of ‘Asperger’s Children: The Origins of Autism in Nazi Vienna’
and the other by Herwig Czech presenting ‘Hans Asperger, National Socialism, and “race hygiene” in Nazi-era Vienna'.
Stepping into the Hofburg in Vienna with an audience of child psychiatrists is definitely a significant place to be for this discussion, and the session has already raised interest and comments. It should not be missed!!